| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
961 |
211 |
$39K |
| D0330 |
Panoramic radiographic image |
1,249 |
1,014 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,277 |
1,047 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
719 |
538 |
$27K |
| D0274 |
Bitewings - four radiographic images |
489 |
439 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
822 |
690 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
142 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
616 |
$4K |
| D1351 |
Sealant - per tooth |
221 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
79 |
61 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
23 |
16 |
$597.28 |
| D0120 |
Periodic oral evaluation - established patient |
35 |
29 |
$403.85 |
| D1110 |
Prophylaxis - adult |
16 |
12 |
$260.00 |
| D1330 |
|
41 |
40 |
$0.00 |
| D0350 |
|
72 |
69 |
$0.00 |